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Home Chiropractic Research Erb's Palsy Chiropractic Care of a Pediatric Patient With Erb’s Palsy

Chiropractic Care of a Pediatric Patient With Erb’s Palsy

Abstract

Introduction: Since the days of Hippocrates, there have been descriptions of children who were unable to move their arms following birth. In 1764, Smellie was the first to describe a bilateral paralysis in a newborn that eventually resolved. In 1872, Duchenne de Boulogne coined the phrase “obstetric brachial plexus palsy” to correlate his findings of excessive tractioning of the brachial plexus during birth and the resultant arm paralysis. The brachial plexus is a group of nerves that include the lower cervical nerve roots C5 – C8 and the first thoracic nerve root T1. Due to their locale through the anterior vertebral foramen past the clavicle and towards the upper extremities, they are easily injured with excessive tractioning of the upper extremities and/or the head, such as during the birth process.  Erb’s classic description of injury to the upper brachial plexus resulting now bears his name. In 1885, Klumpke clinically described the resulting injury to the lower brachial plexus that also bears his name 1.

Anecdotes and testimonials are plentiful in chiropractic on the successful care of patients with obstetric palsy. However, the same could not be said with their documentation in the scientific literature.  To address this deficit, we present the successful chiropractic care of a patient with Erb’s Palsy focusing on its clinical presentation, risk factors, and treatment options. In so doing, we hope to contribute to the development of sound strategies in the care of similar patients under the paradigm of pediatric chiropractic.

Clinical Features: The patient described in this case report was an 8-yr-old female with Erb’s Palsy since birth. According to her mother, the mechanism of injury involved excessive tractioning by  the obstetrician which the patient’s mother described as, “pulling so hard that the bed moved forward.” Prior to her chiropractic consultation, the patient was under medical care which her mother described as visits to the physical therapist. Despite this type of long-term care, the patient continued to experience the consequences of Erb’s Palsy. These involved both cosmetic deformity and dysfunctional use of her right arm and shoulder. According to both the patient and her mother, this restricted the patient’s ability to play with her peers, to participate in gym class and was socially stigmatized.

Upon inspection, the patient demonstrated the pathognomatic waiter’s tip deformity of the right upper extremity. Her right elbow was fixated in flexion at 30°, the ipsilateral forearm fixated in 25° pronation and her right wrist in extension at 40°. Furthermore, there was noticeable scapular winging on the right. Digital palpation of the wrist extensors and flexors revealed muscular rigidity without tenderness as were the muscles of the right shoulder girdle. Active range of motion (ROM) examination was restricted throughout her right upper extremity. At her right elbow, active ROM was restricted on both flexion (AROM: 45°) and extension (AROM: 165°). The patient could not pronate or supinate to end-range  when compared to the left side. With respect to the right glenohumoral joint, restriction and asymmetry was notable throughout all directions on active ROM (see Table 1). Orthopedic testing for the upper extremities was not performed as the patient’s noted deficits were confounders. Neurological examination revealed generalized sensory deficit with respect to Type II and pain and temperature sensations on the right. Myotomal testing was weak at all levels on the right (as compared to the left) with deep tendon reflexes being unremarkable.

Full spine examination of the patient demonstrated the following. Digital palpation of the paraspinal muscles throughout revealed tenderness and hypertonicity at the upper cervical spine muscles (C0-C1 vertebral levels, bilaterally), at the C6-C7 paraspinal muscles (bilaterally), at the T3-T5 paraspinal muscles (bilaterally), and at the L4-L5 paraspinal muscles (bilaterally). Static and motion palpation at the above sites of tenderness revealed segmental dysfunctions at C1, C7, T4, L5 and the right ilium. Tenderness and hypertonicity was also notable at the right upper trapezius muscles, the right levator scapula muscles, the right rhomboid muscles and right teres muscles. Hypertonicity/rigidity was notable at the right deltoid muscles (anterior, middle and posterior), the  right suprascapular muscles, the right infraspinatus muscles, and the right teres major and minor muscles. The bicep and tricep muscles on the right were also hypertonic/rigid to palpation which was progressively worse as one palpated the wrist extensor and flexor muscles. Interestingly, there was not the expected tenderness often seen with muscle hypertonicity. To the contrary, digital pressure to these hypertonic/rigid muscles did not elicit any discomfort for the patient, unlike that seen in other patients that elicit a reflexive withdrawal due to pain and tenderness.

On the first visit, the patient was adjusted using the Diversified Technique at C1 (ASR or -qX, -X) and C7 (PR  or -Z, +qY) in the seated position; T4 (PR or –Z, +qY) in the prone position and at L5 (PR or -Z, +qY) and the right ilium (PI or -qX) in the side posture position. Furthermore, the right scapula was fixated superiorly compared to the left scapula and therefore was adjusted with a high velocity low amplitude thrust in the posterior to anterior and superior to inferior directions, contacting the superior and inferior poles of the right scapula, respectively. There was noticeable improvement in the patient’s right shoulder range of motion - especially on abduction from 15° to 45°. The adjustments were followed with soft-tissue technique that may be described as “myofascial release” to the above described muscles. The wrist flexors and wrist extensor muscles,  the biceps and triceps muscles, the deltoid  muscles, the upper trapezius muscles, the suprascapular and infrascapular muscles as well as the teres muscles. As previously described, in addition to the palpable rigidity of her muscles, she had a high tolerance to the deep digital pressure applied. From our experience with other patients (adults or children), the amount of digital pressure exerted to her was relatively high and yet, she was not the least bit uncomfortable. The above-described approach to patient care was typical of every visit involving full-spine adjusting with myofascial release of the muscles of the right upper extremity as described above. The patient was scheduled 3 times per week for 6 weeks followed by a review and update of the patient’s condition and response to care. During the first 6 weeks, the patient was also instructed to continue her visits to the physical therapist which was described by her mother as mostly resistive exercises in the pool. Following 6 weeks of care, the patient’s overall condition had improved such that her range of motion in the right arm and shoulder had increased. Additionally, her strength in the right arm had also increased as was noticeable on myotomal testing. Given the patient’s positive respone to care, she was scheduled at the same frequency of care for another 6 weeks with continued improvement in her range of motion and strength. Following 3 months of care, the patient was released due to full range of motion of the right elbow and shoulder (see Table 1). The patient’s fixated posture on pronation, elbow flexion and wrist extension were no longer apparent on inspection. Also notable during her care was that with continued improvement, the patient’s tolerance to deep tissue work became less. The muscle rigidity she initially presented with became less and less. Long-term follow up with the patient was positive overall. The patient’s parents were very happy with their daughter’s response to care. So much so that she was rock climbing after a few months of being released from care. She was no longer stigmatized by Erb’s Palsy and was on her way to developing into a confident, active young lady.

 

Intitial Examination

Comparative
(3 months post initial visit)

 

Left

Right

Left

Right

Flexion

180°

25°

180

175

Extension

35°

10°

35

35

Abduction

120°

15°

120

115

Internal Rotation

90°

10°

40

90

External Rotation

90°

10°

45

90

Table 1. Range of motion examination findings of the glenohumoral joints.

Conclusion: The case presented demonstrated that chiropractic care in the form site-specific, high velocity, low amplitude thrusts to sites of vertebral and extravertebral subluxations in combination with soft-tissue work described as myofascial release may be beneficial in patients with long-standing Erb’s Palsy. Continued documentation in the form of case reports/case series as well as higher level research design studies will determine the role of chiropractic care.

References

  1. Terziz JK, Papakonstantinou KC. Management of obstetric brachial plexus palsy. Hand Clinics 1999;15:717-736.

Joey Alcantara, DC 1 and Joel Alcantara, DC 2

  1. Private Practice of Chiropractic, Calgary, AB, Canada
  2. Research Director, International Chiropractic Pediatric Association, Media, PA, USA and Private Practice of Chiropractic, San Jose, CA, USA

Presented at WFC Annual Conference. Portugal, May 2007.

Accepted for publication. Clinical Chiropractic, 2008.